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Managing Pain in the Older Person in the Community

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Managing Pain in the Older Person in the Community Managing pain in the older person in the community Item Type Article Authors Molloy, Niamh Publisher Nursing in General Practice Journal Nursing in General Practice Download date 29/09/2021 05:13:41 Link to Item http://hdl.handle.net/10147/559014 Find this and similar works at - http://www.lenus.ie/hse nursingingeneralpractice clinical review Managing pain in the older person in the community NIAMH MOLLOY, PAIN MANAGEMENT NURSE, UNIVERSITY HOSPITAL WATERFORD PRESIDENT ELECT IRISH PAIN NURSES AND MIDWIVES SOCIETY Introduction acute or chronic, as well as the inferred pathophysiology of pain; Eff ective pain management remains a challenge in modern day nociceptive versus neuropathic or mixed4 or in a clinical context; clinical practice. Managing persistent pain in the older adult en- postsurgical, malignancy related, non malignant, neuropathic counters many challenges and the management of chronic pain or degenerative. Acute pain passes as injury heals while chronic in the community demands a comprehensive understanding of pain persists for three to six months or longer. Neuropathic pain the physiology of pain and pain processing as well as an under- is defi ned as pain arising as a direct consequence of a lesion standing of the various assessment tools available and methods or disease in the somatosensory system.5 Neuropathic pain is to manage pain. It is essential before treating pain that it is associated with disability and reduced quality of life and is often assessed using a recognised pain assessment tool that is valid, underdiagnosed and undertreated.6 Older people can experience reliable and comprehensive. In essence, a holistic approach is re- many types of neuropathic pain including peripheral neuropathy, quired with all aspects of the biopsychosocial model considered.1 central post-stroke pain and postherpetic neuralgia. What is pain? Managing pain in older people Pain is defi ned as an ‘unpleasant sensory and emotional experi- Schofi eld7 suggests a defi nitive prevalence of pain in older peo- ence associated with actual or potential tissue damage or de- ple is impossible to establish. Guidelines for the management of scribed in terms of such damage.2 Pain is also ‘an individual and pain in older adults identifi ed the prevalence of chronic pain in subjective experience modulated by physiological, psychological older people in the community ranged from 25-76 per cent and and environmental factors such as previous events, culture, prog- for those in residential care 83-93 per cent.8 Older women have a nosis, coping strategies, fear and anxiety.’3 higher prevalence of pain.8 Pain can be classifi ed according to length of duration; whether The three most common sites of pain in older people are the 27 clinical review nursingingeneralpractice back, leg/knee or hip and other joints.8 Pain may be present in the use of adapted scales for those who have difficulties with more than one location which can cause further disability for the communication. Consider using alternative words for describing patient and social isolation. pain which the patient may associate more closely with such as Older people are at risk of chronic pain due to multiple soreness, hurts or discomfort.18 conditions such as osteoarthritis, diabetic neuropathy, leg ulcers and cancer as well as pain due to surviving cancers. Multi- Assessing pain in cognitive impairment morbidities, which combined with the possibility of reduced Mildly cognitively impaired individuals are almost as able as cognition and sensory impairment, can impact significantly on those without a cognitive impairment to accurately report their level of function and increase disability. pain.19 Individuals with mild forms of dementia are usually able Managing pain in older people is difficult due to the to communicate their pain experience, but this ability is lost presence of multi-morbidities, polypharmacy and sensitivity with more advanced dementia.10 The use of a body chart for the to medications9 as well as potential drug interactions and patient to identify the location of their pain is particularly helpful. drug-disease interactions. Good pain management is essential Pain should be discussed in the present tense using a scale the to support and maintain independent living. Sleep, mobility, patient understands, for example, the Numerical Rating Scale, appetite and mood can be negatively affected by pain while side effects of medications can include anticholinerigic side effects, constipation, nausea and vomiting and the risk of falls. Dewar9 suggests older people may be reluctant to report pain and have a stoic approach, accepting incorrectly that pain is part of the normal aging process. Pain is not a normal part of ageing, but its prevalence increases with age and illness, reaching its highest levels among older people in residential care settings.10 For persistent pain which is resistant to common therapies, Older people may be medications or alternative methods, the health care professional should consider referral to specialist pain clinics.10 In 2005, Schofield et al.11 suggested the need for chronic pain reluctant to report services in the community; in the current climate, this is more evident than ever. In jurisdictions that are moving forward with pain and have a stoic a national strategy for pain (such as Australia), this is already happening; specialist pain teams are moving into the heart of the issue in primary care.12 approach, accepting Assessment of pain incorrectly that pain A patient’s own report is the most reliable indicator of their pain and when possible this should be obtained.4 A self-report of pain is also possible in those with mild to is part of the normal moderate cognitive impairment with standard assessment tools or if required with more specialised tools such as the Iowa Pain aging process. Thermometer.13 Pain assessment offers patients the opportunity to make a largely subjective experience objective.14 There are multiple assessment tools available to facilitate initial and ongoing assessment of patient pain.15 However, pain assessment is only of value if it is used to guide selection of comprehensive treatments and interventions and to determine the effectiveness of those interventions. Pain assessment must lead to changes Verbal Descriptor Scale or the Iowa Pain Thermometer. The nurse in management and the patient’s pain should be re-evaluated should ensure if assistive devices such as a hearing aid or glasses following these changes to ensure improvements in the are usually required that these are in place.18 (See figure 1: Algo- quality of care.16 The pain assessment tool chosen should be rithm for the assessment of pain in the older person18). Appropri- appropriate to the individual patient taking into consideration ate time should be given for the assessment and be consistent their developmental, cognitive, emotional, language and with the scale used. cultural factors.3 Unidimensional pain scales such as the Numeric Assessing pain in those with cognitive impairment involves Rating Scale, Verbal Descriptor Scale, Iowa Pain Thermometer a three step approach; self-report, caregiver reports and direct although useful, only measure the intensity of pain. Multi- observation.17 In severe cognitive impairment an observational dimensional scales exist and initial assessment would benefit assessment of pain is necessary. During the assessment process from the use of a multi-dimensional tool such as the Short Form it is essential to obtain insight into behaviour from family McGill Pain Questionnaire or the Brief Pain Inventory in the members and carers as a change in behaviour is particularly community.17Subsequent assessment could then be performed important. Stewart et al.17 suggest studies show the Pain with a unidimensional tool as preferred by the patient.12 Assessment Checklist for Seniors with Limited Ability to Nurses should offer assistance with self-report of pain through Communicate (PACSLAC), Abbey Pain Scale and Doloplus-2 as 28 nursingingeneralpractice clinical review the most encouraging scales to use in this patient group. If pain drug-disease interactions. Studies also demonstrate a correlation is suspected, but efforts to assess pain prove difficult, attempt between increasing age and adverse drug reaction.23 an analgesic trial in a structured manner using the World Health While analgesia is safe to use in older people, it should Organisation (WHO) three step analgesic ladder20 and observe be titrated to response8 and age should not be a reason for the patient for effects including side effects.21 withholding treatment.23 Regular administration of simple Updated guidelines on assessing pain in older people are due analgesics such as paracetamol for continuous pain may be to be published shortly by the British Pain Society in conjunction sufficient to reduce pain to a level that allows the person to with the British Geriatric Society. function more independently. The WHO three step analgesic ladder20 originally existed for use with patients with pain Pharmacological management of pain associated with cancer. It is now widely used to manage pain in a Pain is best managed using a multimodal approach, which variety of settings including acute and community care. As pain consists of the use of two or more different classes of analge- severity increases (or decreases), pharmacological management sia targeting different mechanisms of pain.4 8 Optimising pain needs to move up (or down) the ladder utilising stronger (or management is
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